RESTRICTED UNTIL APPROVED Epilepsy in Pregnancy Guideline Guideline Number: 633 Supersedes: Classification Clinical Version No: Date of EqIA: Approved by: Date Approved: Date made active: Review Date: 1 Obstetric Written Documentation Review Group 14/09/2017 20/09/2017 14/09/2018 Brief Summary of Document: Guideline on pregnancy in epilepsy Scope To be read in conjunction with: Owning group Obstetric Written Documentation Review Group 1 of 5 V0.3
Version no: Summary of Amendments: Reviews and updates Date Approved: 1 New guideline 14/9/2017 Glossary of terms Term Definition Keywords Epilepsy, pregnancy, contraception Database No: 633 Page 2 of 5 Version 1.0
Contents 1. INTRODUCTION... 4 2. PRECONCEPTUAL CARE... 4 3. ANTENATAL MANAGEMENT... 5 4. INTRAPARTUM CARE... 5 5. POSTNATAL MANAGEMENT... 5 6. REFERENCES... 5 Database No: 633 Page 3 of 5 Version 1.0
1. INTRODUCTION Most women with epilepsy who are receiving optimal treatment for their epilepsy, and who are well-informed, supported and fully counselled have uncomplicated pregnancies, normal deliveries, and healthy children. However, there are a number of important health-related issues relating to the diagnosis of epilepsy and the use of AEDs in women of child-bearing age. AEDs are associated with teratogenic effects and uncontrolled seizures can cause adverse effects during pregnancy. Conversely, pregnancy and the menstrual cycle can affect seizure control due to hormonally induced alteration of the seizure threshold. In 54% of women with epilepsy there is no change in the frequency of fits. In 25-30% fit frequency will increase. Epilepsy is the second commonest indirect cause of maternal death in the UK. 2. PRECONCEPTUAL CARE Women should be advised to contact their primary care provider to discuss preparing for planned pregnancies. Women need good contraceptive advice to ensure that all pregnancies are planned. following are drugs that may affect the efficacy of oral contraceptives: Carbamazepine (Tegretol) Oxcabazepine (Trileptal) Phenytoin (Epanutin) Topiramate (Topamax) Primidone Phenobarbitone (Mysoline) The It is recommended that women taking any of the above take at least 50 micrograms of oestrogen which equates to two normal 30 microgram tablets. It is also recommended that women take their pills for three cycles consecutively with a shorter four day break. Women on the progesterone only pill should seek advice about other forms of contraception ie Depo Provera or Mirena IUD which are not affected by enzyme induction. Follow the RCOG guidance for emergency contraception. A review of anticonvulsant medication should aim for monotherapy to reduce the risk of teratogenesis. Women may stop anticonvulsant medication for the first trimester if they have been fit free for more than two years. However this will need to be discussed with the neurology team. Major malformation caused by anticonvulsants are: NTD s valproate 1-2%, carbemazepine 0.5-1%. Orofacial clefts phenytoin CHD, phenytoin and valproate. Database No: 633 Page 4 of 5 Version 1.0
The risk for any one drug is 6-7% ie x2 back ground risk. For valproate the risk is dose dependant. For women taking 2 drugs the risk is doubled. The risk of a child having epilepsy if either parent has the condition is 5%.If there is a previously affected sibling the risk is 10%. Folic acid 5mg once daily should be started as soon as contraception is stopped. All women should receive 5mg folic acid for at least 3 months prior to any possibility of 3. ANTENATAL MANAGEMENT Continue Folic acid throughout pregnancy at a dose of 5mg All pregnant women with epilepsy should notify their pregnancy or allow their Obstetrician to notify the UK Epilepsy and Pregnancy Register. If the patient is fit free monitoring of plasma drug levels is not recommended. In women who have regular seizures it may be worth monitoring levels as they will fall. There is no need to change anticonvulsant therapy in pregnancy if the woman is well controlled. Phenobarbitone may be weaned or changed due to potential risk of neonatal withdrawal convulsions. Information should be given to all patients on safety precautions. Relatives or friends should be instructed on how to place the woman in the recovery position in the event of a seizure. Woman should be advised to shower or bath in shallow water and not to bathe alone in the house or with the door locked. Vitamin K 10mg should be given once daily during the last 4-6 weeks of pregnancy in those patients taking enzyme inducers (carbemazepine, phenytoin, phenobarbitone). 4. INTRAPARTUM CARE H The risk of seizures increases around delivery. Continue usual medication in labour Fits may be controlled by IV or rectal Diazepam Patients may receive the same analgesia in labour Babies must receive Vitamin K 1mg IM at birth 5. POSTNATAL MANAGEMENT There is no reason why mothers on antiepileptic medication should not breastfeed, all should be encouraged to breast feed. Possible exceptions are phenobarbitone and Primidone. Information on safe conduct at home ie changing nappies on the floor, not bathing with the baby when alone at home, not carrying the baby down the stairs should be given. 6. REFERENCES The Epilepsies NCGC 2012 National Clinical Guideline Centre Clinical Guideline 20 Catherine Nelson Piercy. Ed.Dunitz2002 Handbook of obstetric medicine. NICE Epilepsy CG137 Jan 2012 Database No: 633 Page 5 of 5 Version 1.0